Both arthroscopic one-step Broström-Gould and Lasso-loop stitch techniques achieved favourable clinical outcomes for chronic lateral ankle instability.

PURPOSE: Both the arthroscopic Broström-Gould and Lasso-loop stitch techniques are commonly used to treat chronic lateral ankle instability (CLAI). The purpose of this study is to introduce an arthroscopic one-step outside-in Broström-Gould (AOBG) technique and compare the mid-term outcomes of the AOBG technique and Lasso-loop stitch technique. METHODS: All CLAI patients who underwent arthroscopic lateral ankle stabilization surgery in our department from 2018 to 2019 were retrospectively enrolled. The patients were divided into two groups according to the surgical methods employed: the AOBG technique (Group A) and the Lasso-loop technique (Group B). The visual analogue scale pain score, American Orthopaedic Foot and Ankle Society ankle hindfoot score, Tegner activity score and Karlsson-Peterson score were evaluated preoperatively and during the follow-up from June to December 2022. The surgical duration, return to sports, sprain recurrence and surgical complications were also recorded and compared. RESULTS: A total of 74 patients (Group A, n = 42; Group B, n = 32) were included in this study with a mean follow-up of 39 months. No statistically significant differences were observed in demographic parameters or follow-up time between the two groups. Postoperative clinical scores indicated a significant improvement (all with p < 0.001) with no significant difference between the two groups (not significant [n.s.]). There was no significant difference in the surgical duration (46.1 vs. 49.7 min, n.s.), return to sports (92.9% vs. 93.8%, n.s.), or sprain recurrence (4.8% vs. 6.3%, n.s.). Only two cases in Group A reported knot irritation (4.8% vs. 0, n.s.), and one case in Group A experienced local skin numbness (0 vs. 3.1%, n.s.), with no significant difference. CONCLUSION: Both the AOBG and Lasso-loop stitch techniques yielded comparable favourable mid-term outcomes and return to sports with a low rate of surgical complications. Both procedures could be feasible strategies for CLAI patients. LEVEL OF EVIDENCE: Level III.

Balance training benefits chronic ankle instability with generalized joint hypermobility: a prospective cohort study.

BACKGROUND: Balance training is the first choice of treatment for chronic ankle instability (CAI). However, there is a lack of research on the effects of balance training in CAI with generalized joint hypermobility (GJH). This study is to compare the outcomes of balance training in CAI patients with and without GJH. METHODS: Forty CAI patients were assigned into the GJH group (Beighton ≥ 4, 20) and non-GJH group (Beighton < 4, 20) and they received same 3-month supervised balance training. Repeated measure ANOVA and independent t test were used to analyze self-reported questionnaires (Foot and ankle ability measure, FAAM), the number of patients experiencing ankle sprain, isokinetic muscle strength and postural control tests (Star excursion balance test, SEBT and Balance errors system, BES) before training, post-training immediately, and post-training 3 months, respectively. RESULTS: At baseline, no differences were found between groups with except for GJH group having poorer SEBT in the posteromedial direction (83.6 ± 10.1 vs 92.8 ± 12.3, %) and in the posterolateral direction (84.7 ± 11.7 vs 95.7 ± 8.7, %). Following the balance training, GJH group demonstrated lower re-sprain ratio (immediately after training, 11.1% vs 23.5%, 3 month after training, 16.7% vs 29.4%) than non-GJH group, as well as greater FAAM-S score, plantarflexion strength and dorsiflexion strength at post-training immediately and 3 months, and both groups improved similarly in the FAAM-A score, muscle strength and balance control (SEBT in the posterior-lateral and posterior-medial directions, and BES scores) compared with baseline. CONCLUSIONS: CAI patients with GJH gained equally even better postural stability and muscle strength after the balance training than the non-GJH patients. Balance training could still be an effective treatment for CAI patients with GJH before considering surgery. TRIAL REGISTRATION: ChiCTR1900023999, June 21st, 2019.

Both Open and Arthroscopic All-Inside Anatomic Reconstruction With Autologous Gracilis Tendon Restore Ankle Stability in Patients With Chronic Lateral Ankle Instability.

PURPOSE: To compare the return to sports and short-term clinical outcomes between the arthroscopic all-inside and the open anatomic reconstruction with gracilis tendon autograft for chronic lateral ankle instability (CLAI) patients. METHODS: From March 2018 to January 2020, 57 CLAI patients were prospectively included with arthroscopic all-inside anatomic reconstruction (n = 31) or open anatomic reconstruction (n = 26) with gracilis tendon autograft. The patients were evaluated before operation and at 3 months, 6 months, 12 months, and 24 months after surgery. The American Orthopaedic Foot and Ankle Society score (AOFAS), visual analog scale (VAS), and Karlsson-Peterson score were evaluated at each time point, and stress radiography with a Telos device was performed before surgery and at final follow-up. The time to return to full weightbearing walking, jogging, sports, and work, Tegner activity score, and complications were recorded and compared. RESULTS: All the subjective scores significantly improved after surgery from the preoperative level. Compared with the open group, the arthroscopic group demonstrated significantly earlier return to full weightbearing walking (8.9 vs 11.7 weeks, P < .001), jogging (17.9 vs 20.9 weeks, P = .012), and recreational sports (22.4 vs 26.5 weeks, P = .001) with significantly better AOFAS score and Karlsson score at 3 to 6 months, and better VAS score at 6 months after surgery. The 2 groups demonstrated no significant difference in the surgical duration or surgical complications. No significant difference was found in the clinical scores or stress radiographic measurements at 24 months after surgery (P > .05). CONCLUSION: Compared with the open procedure, the arthroscopic all-inside anatomic lateral ankle ligament reconstruction with autologous gracilis tendon could achieve earlier return to full weightbearing, jogging, and recreational sports with less pain and better ankle functional scores at 3 to 6 months after surgery. Similar favorable short-term clinical outcomes were achieved for both techniques at 2 years after surgery. STUDY DESIGN: Level I, randomized controlled trial.

Arthroscopic modified Broström procedure achieved similar favorable short term outcomes to open procedure for chronic lateral ankle instability cases with generalized joint laxity.

PURPOSE: To compare the short-term clinical outcomes of the open versus arthroscopic modified Broström procedure in generalized joint laxity (GJL) patients. METHODS: From January 2018 to January 2020, 64 consecutive patients with chronic lateral ankle instability (CLAI) and GJL (Beighton score ≥ 4) were prospectively enrolled into two groups: those who underwent the open modified Broström procedure (open group, n = 32) and those who underwent the arthroscopic modified Broström procedure (arthroscopic group, n = 32). Patients underwent an open or arthroscopic modified Broström procedure based on the time when they attended the clinic for consultation. All patients were followed-up at 3, 6, 12, and 24 months postoperatively. The clinical outcomes were evaluated using the visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, and Karlsson score, and the radiographic outcomes were assessed using stress radiography at 24 months postoperatively. The time to return to work and the failure rate were also evaluated and compared. RESULTS: Follow-up was completed for 31 patients in the open group and 30 patients in the arthroscopic group. No significant differences were found between the two groups in terms of demographic characteristics, Beighton score (6.2 ± 1.9 vs. 5.5 ± 1.4, n.s.), or duration of symptoms. There were no significant differences in the functional scores before surgery and at 6, 12 and 24 months postoperatively or in the mean anterior translation of the talus and talar tilt angle on stress radiography at 24 months postoperatively between the open and arthroscopic groups. Compared to the open group, the arthroscopic group showed a significantly earlier return to work (6.8 ± 2.1 vs. 8.1 ± 2.4 weeks, p = 0.006). There was no significant difference in terms of the failure rate between the open and arthroscopic groups (16.1% vs. 23.3%, n.s.). CONCLUSION: Arthroscopic modified Broström procedure achieved similar short-term outcomes to the open procedure for GJL patients. Arthroscopic modified Broström procedure showed an earlier return to work than the open modified Broström procedure and was an alternative to open surgery for CLAI patients with GJL. LEVEL OF EVIDENCE: III. CLINICAL TRIAL REGISTRATION: This study is a prospective study NCT05284188.

Anatomic reconstruction using the autologous gracilis tendon achieved less sprain recurrence than the Broström-Gould procedure but delayed recovery in chronic lateral ankle instability.

PURPOSE: To compare the return-to-activity and long-term clinical outcomes between anatomic lateral ligament reconstruction using the autologous gracilis tendon and modified Broström-Gould (MBG) procedure in chronic lateral ankle instability (CLAI). It was hypothesised that there was no difference between the two techniques. METHODS: From 2013 to 2018, 30 CLAI patients with grade III joint instability confirmed by anterior drawer test underwent anatomic reconstruction of lateral ankle ligament with the autologous gracilis tendon (reconstruction group) in our institute. Another 30 patients undergoing MBG procedure (MBG group) were matched in a 1:1 ratio based on demographic parameters. The post-operative American Orthopaedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) pain score, Tegner activity score, Karlsson-Peterson score, surgical complications, return-to-activities and work were retrospectively evaluated and compared between the two groups. RESULTS: All subjective scores significantly improved after the operation (all with p < 0.001) without difference between the two groups (all n.s.). The MBG group showed a significantly higher proportion of postoperative sprain recurrence than the reconstruction group (26.7% vs. 0, p = 0.002). The reconstruction group showed a significantly longer period to start walking with full weight-bearing (10.5 ± 6.9 vs. 7.0 ± 3.1 weeks, p = 0.015), jogging (17.1 ± 8.9 vs. 12.7 ± 6.9 weeks, p = 0.043) and return-to-work (13.5 ± 12.6 vs. 8.0 ± 4.7 weeks, p = 0.039) than the MBG group. CONCLUSIONS: Both anatomic reconstruction using the autologous gracilis tendon and MBG procedure could equally achieved reliable long-term clinical outcomes and the tendon reconstruction showed a relatively lower incidence of postoperative sprain recurrence but delayed recovery to walking, jogging and return-to-work. The MBG procedure was still the first choice with rapid recovery but the tendon reconstruction was recommended for patients with higher strength demand. LEVEL OF EVIDENCE: III.

Arthroscopic modified Broström procedure achieves faster return to sports than open procedure for chronic ankle instability.

PURPOSE: To compare the clinical outcomes, rate of return to sports, postural control, and muscle strength between the arthroscopic and open modified Broström procedure for chronic lateral ankle instability (CLAI) patients. METHODS: From September 2018 to April 2019, 70 patients diagnosed with CLAI were prospectively included with arthroscopic modified Broström procedure (n = 36) and open modified Broström procedure (n = 34). They were evaluated at five time points (preoperation and 3 months, 6 months, 1 year and 2 years postoperatively). The main results examined the rate of return to sports, American Orthopaedic Foot and Ankle Society Score (AOFAS), Foot and Ankle Ability Measure (FAAM), visual analogue scale (VAS), centre of pressure (COP) excursion velocity, time to boundary (TTB), plantar pressure, isokinetic muscle strength and complications. RESULTS: Compared with the open group, the arthroscopic group demonstrated a significantly shorter period of return to the preinjury sport (13.2 ± 2.4 weeks vs. 18.7 ± 3.1 weeks, P = 0.023) and a higher early sport ratio (80.6 vs. 61.8%, P = 0.011) combined with better FAAM sports and AOFAS at 3 months and 6 months postoperatively and VAS at 3 months postoperatively. In addition, better anterior-posterior postural control stability, less time to peak force under lateral hindfoot and better dorsiflexion strength were shown in the arthroscopic group at 6 months postoperatively. No significant difference was found in clinical scores, posture control or muscle strength at the 1- or 2-year follow-up between the two groups. CONCLUSIONS: Shorter period and higher rates of return to sport activities and better clinical scores, posture control and muscle strength were achieved in the arthroscopic group at 6 months postoperatively, and no clinical differences were found between arthroscopic and open modified Broström procedure 1 year or 2 years postoperatively. Arthroscopic modified Broström procedure is a reliable procedure for CLAI injuries with the demand for fast exercise recovery. CLINICAL REGISTRATION: ChiCTR1900023999. LEVEL OF EVIDENCE: II.

The L-shaped tunnel technique showed favourable outcomes similar to those of the Y-graft technique in anatomic lateral ankle ligament reconstruction.

PURPOSE: To compare the mid- to long-term clinical and radiological outcomes of the confluent L-shaped tunnel technique with the Y-graft technique for anatomic lateral ankle ligament reconstruction. METHODS: This retrospective study involved 41 patients who underwent lateral ankle ligament reconstruction between 2013 and 2018. Based on the tunnel direction and tendon fixation method at the fibula side, patients were divided into two groups, with 17 patients in the L-shaped tunnel group and 24 patients in the Y-graft group. The American Orthopaedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) pain score, Tegner score, and Karlsson score were evaluated and compared preoperatively and at follow-up. Anterior talar translation and talar tilt at stress radiographs, postoperative sprain recurrence, range of motion (ROM) restriction, sensory disturbance, etc., were also collected and compared. RESULTS: The mean follow-up times were 72 and 42 months for the L-shaped group and Y-graft group, respectively. The median VAS pain score, Tegner score, AOFAS score, Karlsson score significantly improved from a preoperative level in both groups (all with p < 0.01). No significant difference was found between the two groups regarding the changes from preoperatively to postoperatively except for the VAS pain score reduction (1.58 ± 1.58 in the L-shaped group vs. 2.53 ± 1.29 in the Y-graft group, p = 0.035). The incidence of flexion-extension ROM restriction (≥ 5°) was significantly higher in the Y-graft group (41.2%) than in the L-shaped group (12.5%) (p = 0.035). CONCLUSIONS: Both the confluent L-shaped tunnel technique and the Y-graft technique significantly improved symptoms, ankle function, and radiographic outcomes in patients with chronic lateral ankle instability (CLAI) at mid- to long-term follow-up. The confluent L-shaped tunnel technique resulted in lower rates of flexion-extension ROM restriction, while the Y-graft technique showed better VAS pain reduction. This result could provide further evidence for the surgical treatment of CLAI. LEVEL OF EVIDENCE: III.

Secondary Effects of the Rupture and Reconstruction of the Interosseous Talocalcaneal Ligament on the Peritalar Joints.

BACKGROUND The interosseous talocalcaneal ligament (ITCL) is the main soft-tissue contributor to subtalar joint stability. The role of ITCL reconstruction in retaining this stability is minimally reported. Therefore, we conducted this study to investigate the effects of rupture and reconstruction of the ITCL on the subtalar and peritalar joints. MATERIAL AND METHODS This experimental study randomly divided 72 rabbits into 3 equal groups of 24 rabbits each. Group I underwent reconstruction surgery, group II underwent resection, and group III was the control group. The cartilages between the talocrural and calcaneocrural joints, and between the subtalar and talonavicular joints on both sides were assessed by gross observation, ink staining, histology, and immunohistochemistry at weeks 4, 8, 16, and 32, postoperatively. RESULTS In group II, the quantitative ink staining analysis revealed degeneration of the articular cartilages on the talonavicular joint (T=2.070, P=0.038) and the posterior subtalar joint (T=2.121, P=0.034) compared with the 2 sides of the same rabbit at 4 and 8 postoperative weeks. Comparing the operated sides of all the groups showed the posterior subtalar joints (Hc=9.563, P=0.008) and talonavicular joints (Hc=9.714, P=0.008) had an obvious difference at postoperative week 4; and in the calcaneocrural joints (Hc=6.750, P=0.034), it was noticed at postoperative week 8. Histology and immunohistochemistry findings confirm these observations. CONCLUSIONS An ITCL resection can lead to the progressive degeneration of the talonavicular and posterior subtalar joints, while an ITCL reconstruction can be beneficial in restoring the stability of these joints, preventing or postponing their degeneration, and protecting the articular cartilages.

Characteristics and predictors of muscle strength deficit in mechanical ankle instability.

PURPOSE: Muscle strength training is a common strategy for treating chronic ankle instability (CAI), but the effectiveness decreases for mechanical ankle instability (MAI) patients with initial severe ligament injuries. The purpose of this study was to investigate the characteristics and the potential predictors of muscle strength deficit in MAI patients, with a view to proposing a more targeted muscle strength training strategy. METHODS: A total of 220 MAI patients with confirmed initial lateral ankle ligament rupture and a postinjury duration of more than 6 months were included. All patients underwent a Biodex isokinetic examination of the ankle joints of both the affected and unaffected sides. Then, the associations between the limb symmetry index (LSI) (mean peak torque of the injury side divided by that of the healthy side) and the patients' sex, body mass index, postinjury duration, presence of intra-articular osteochondral lesions, presence of osteophytes and ligament injury pattern (i.e., isolated anterior talofibular ligament (ATFL) injury or combined with calcaneofibular ligament injury) were analysed. RESULTS: There was significantly weaker muscle strength on the affected side than on the unaffected side in all directions (p < 0.05). The LSI in plantar flexion was significantly lower than that in dorsiflexion at 60°/s (0.87 vs 0.98, p < 0.001). A lower LSI in eversion was significantly correlated with female sex (0.82 vs 0.94, p = 0.016) and isolated ATFL injury (0.86 vs 0.95, p = 0.012). No other factors were found to be associated with muscle strength deficits. CONCLUSION: MAI patients showed significant muscle strength deficits on the affected side, especially in plantar flexion. There were greater strength deficits in eversion in females and individuals with an isolated ATFL injury. Thus, a muscle strength training programme for MAI patients was proposed that focused more on plantar flexion training and eversion training for females and those with an isolated ATFL injury.

The effect of cyclic knee motion on the elongation of four-strand hamstring autograft in anterior cruciate ligament reconstruction: an in-situ pilot study.

BACKGROUND: Pretension of the viscoelastic graft by cyclic knee motion has been confirmed to decrease the graft creep and improve the outcome of anterior cruciate ligament (ACL) reconstruction. The purpose of the present study was to investigate the effect of cyclic knee motion on the elongation of the four-strand hamstring tendon autograft in situ and to explore the stable level cycle, in which the tendon length achieved a stable level. METHODS: The study was performed with 53 consecutive patients undergoing transtibial ACL reconstruction with four strand hamstring tendon from Aug 2013 to Apr 2015. 43 males and 10 females were included with mean age of 29 ± 10 years. The pretension of the tendons was operated by cyclical knee motion ranging from 0 to 110°after the femoral fixation with Endo-button. The tendon length after 10, 20, 30 and 40 cycles was measured respectively and compared by repeated measure ANOVA. Then multivariate logistic regression was used to investigate the effect of the patients' parameters (age, gender, height, body weight, tendon length, etc.) on the elongation of the graft and the stable level cycle. RESULTS: The mean lengthening of the graft at 10, 20, 30 and 40 times was 3.0 ± 1.4 mm, 4.3 ± 1.5 mm, 4.8 ± 1.7 mm and 4.8 ± 1.8 mm respectively. No significant correlation was found between the elongation and the patients' parameters. There was significant difference of the tendon length from 0 to 30 cycles (F = 264.8, df = 1.95, p<0.001). However, the tendon length achieved a stable level after 30 cycles and the median elongation from 30 cycles to 40 cycles was 0 (0-1) mm with no significant difference (F = 2.039, p = 0.159). The male and female tendon length achieved to a stable level at 20 cycles and 30 cycles respectively but with no significant difference (p = 0.074). CONCLUSIONS: The four-strand hamstring tendon was elongated after cyclic knee motion and the elongation achieved a stable level after 30 cycles for the transtibial technique. Both of the tendon elongation and the stable level cycle were not correlated with patients' gender, age, preoperative duration, graft diameter and length.

Concurrent arthroscopic osteochondral lesion treatment and lateral ankle ligament repair has no substantial effect on the outcome of chronic lateral ankle instability.

PURPOSE: The purpose of the study was to evaluate the effect of concurrent arthroscopic osteochondral lesion (OCL) treatment and lateral ankle ligament repair on the outcome of chronic lateral ankle instability. It was hypothesized that the arthroscopic OCL treatment might have some negative effect on the outcome of chronic lateral ankle instability (CLAI) by compromising the rehabilitation program. METHODS: Ankle arthroscopy and anatomic lateral ankle ligament repair with suture anchors were performed for 70 patients with CLAI between 2010 and 2012. Thirty-four patients (group A), 20 males and 14 females with a median age of 30(14-54) years, received arthroscopic abrasion, curettage, drilling, or microfracture for OCLs. The splint was removed daily for joint motion exercises beginning at post-operative 2 weeks and full weight bearing was allowed between post-operative week 8 and 12. The other 36 patients (group B) with no combined OCL were followed up as controls. Pre-operative and post-operative visual analog scale (VAS) scores, American Orthopaedic Foot and Ankle Society (AOFAS) scores, Tegner scores, sprain recurrence, ankle stability, and range of motion (ROM) were evaluated and compared. RESULTS: The median follow-up was 46.5 (38-55) months and 44.5 (38-56) months for group A and group B, respectively. The median post-operative VAS score, AOFAS score, and Tegner score were improved from the pre-operative level for both groups with good-to-excellent results for more than 90% patients. No significant difference was found between the two groups for the subjective scores and satisfaction rate (n.s.). Recurrent sprain was found among nine patients(26.5%) of the group A and five patients (13.9%) of the group B (n.s.). The incidence of the ROM restriction of group A was significantly higher than in group B (23.5 vs 5.6%, P = 0.043). CONCLUSIONS: The concurrent arthroscopic treatment of OCL with lateral ankle ligament repair demonstrated no substantial negative effect on the overall mid-term outcome of the patients with CLAI except for a potential risk of ROM restriction. LEVEL OF EVIDENCE: III.

Proteomic insight into fruit set of cucumber (Cucumis sativus L.) suggests the cues of hormone-independent parthenocarpy.

BACKGROUND: Parthenocarpy is an excellent agronomic trait that enables crops to set fruit in the absence of pollination and fertilization, and therefore to produce seedless fruit. Although parthenocarpy is widely recognized as a hormone-dependent process, hormone-insensitive parthenocarpy can also be observed in cucumber; however, its mechanism is poorly understood. To improve the global understanding of parthenocarpy and address the hormone-insensitive parthenocarpy shown in cucumber, we conducted a physiological and proteomic analysis of differently developed fruits. RESULTS: Physiological analysis indicated that the natural hormone-insensitive parthenocarpy of 'EC1' has broad hormone-inhibitor resistance, and the endogenous hormones in the natural parthenocarpy (NP) fruits were stable and relatively lower than those of the non-parthenocarpic cultivar '8419 s-1.' Based on the iTRAQ technique, 683 fruit developmental proteins were identified from NP, cytokinin-induced parthenocarpic (CP), pollinated and unpollinated fruits. Gene Ontology (GO) analysis showed that proteins detected from both set and aborted fruits were involved in similar biological processes, such as cell growth, the cell cycle, cell death and communication. Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis revealed that 'protein synthesis' was the major biological process that differed between fruit set and fruit abortion. Clustering analysis revealed that different protein expression patterns were involved in CP and NP fruits. Forty-one parthenocarpy-specialized DEPs (differentially expressed proteins) were screened and divided into two distinctive groups: NP-specialized proteins and CP-specialized proteins. Furthermore, qRT-PCR and western blot analysis indicated that NP-specialized proteins showed hormone- or hormone-inhibitor insensitive expression patterns in both ovaries and seedlings. CONCLUSIONS: In this study, the global molecular regulation of fruit development in cucumber was revealed at the protein level. Physiological and proteomic comparisons indicated the presence of hormone-independent parthenocarpy and suppression of fruit abortion in cucumber. The proteomic analysis suggested that hormone-independent parthenocarpy is regulated by hormone-insensitive proteins such as the NP-specialized proteins. Moreover, the regulation of fruit abortion suppression may be closely related to protein synthesis pathways.

Effect of Arthroscopically Confirmed Syndesmotic Widening on Outcome Following Isolated Broström Operation for Chronic Lateral Ankle Instability.

BACKGROUND: Tibiofibular syndesmosis (TFS) widening sometimes is not evident on radiography but can be found under arthroscopy in chronic lateral ankle instability (CLAI). This study aimed to evaluate the effect of TFS widening severity on clinical outcomes and return to activities after isolated Broström operation in CLAI patients and to propose an indication for its surgical intervention. METHODS: A total of 118 CLAI patients undergoing diagnostic ankle arthroscopy and open Broström-Gould operation were included. Based on the middle width of TFS measured under arthroscopy, patients were divided into the TFS-2 group (≤2 mm, n = 44), the TFS-3 group (2-4 mm, n = 42), and the TFS-4 group (≥4 mm, n = 32). The time to return to recreational sport and work, Tegner activity score, and proportion of returning to preinjury sports at the final follow-up were evaluated and compared. Other subjective evaluations included the American Orthopaedic Foot & Ankle Society score, visual analog scale, and Karlsson-Peterson score. RESULTS: Among the 3 groups, the TFS-4 group demonstrated the longest mean time to return to work and recreational sports, with the lowest proportion returning to preinjury sports. The TFS-4 group showed a significantly higher rate of sprain recurrence (12.5%) than the other 2 groups (P =.021). All the other subjective scores significantly improved after the operation without differences among the 3 groups. CONCLUSION: Concomitant severe syndesmotic widening adversely affects the return to activities after Broström operation in CLAI cases. The CLAI patients with a middle TFS width ≥4 mm were associated with delayed return to work and sports, a lower proportion of returning to preinjury sports, and more sprain recurrence, which might require further surgical intervention for syndesmosis in addition to Broström surgery. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Advances in the Application of Three-dimensional Printing for the Clinical Treatment of Osteoarticular Defects.

As a promising manufacturing technology, three-dimensional (3D) printing technology is widely used in the medical field. In the treatment of osteoarticular defects, the emergence of 3D printing technology provides a new option for the reconstruction of functional articular surfaces. At present, 3D printing technology has been used in clinical applications such as models, patient-specific instruments (PSIs), and customized implants to treat joint defects caused by trauma, sports injury, and tumors. This review summarizes the application status of 3D printing technology in the treatment of osteoarticular defects and discusses its advantages, disadvantages, and possible future research strategies.

[Expert consensus of the third-generation minimally invasive technical specification for hallux valgus].

The expert consensus of the third-generation minimally invasive technical specification for hallux valgus was developed by Foot and Ankle Committee of Orthopaedic Branch of Chinese Medical Doctor Association, Foot and Ankle Committee of Sports Medicine Branch of Chinese Medical Doctor Association, and Foot and Ankle Expert Committee of Orthopedic Branch of Chinese Association of Integrative Medicine. The consensus was drawn from evidence-based medicine and experts' clinical experience to provide an academic guidance of the third-generation minimally invasive technical specification of hallux valgus for the orthopedic surgeons, including definition, indications, osteotomy techniques, post-operative rehabilitation and prognosis.

Simultaneous Treatment of Osteochondral Lesion Does Not Affect the Mid- to Long-Term Outcomes of Ligament Repair for Acute Ankle Sprain: A Retrospective Comparative Study with a 3-11-Year Follow-up.

Purpose: This study aims to evaluate the mid- to long-term outcome of concurrent arthroscopic treatment of osteochondral lesion (OCL) and open anatomical repair of lateral ankle ligaments for severe acute ankle sprain patients and compare them to the outcome of those without OCL. Methods: A total of 166 patients with grade III acute lateral ankle ligament injuries underwent concurrent ankle arthroscopy and open anatomic ligament repair. Forty-three patients (group A) with OCL underwent arthroscopic treatment followed by open ligament repair. A total of 105 patients (group B) without OCL were followed up as the control. The evaluation parameters included sports recovery, postoperative visual analog scale (VAS) pain score, American Orthopaedic Foot and Ankle Society (AOFAS) score, Tegner score, sprain recurrence, satisfaction, and range of motion. Patients in group A were then subgroup-analyzed according to age, sex, body mass index, injury side, OCL location, and stage (Ferkel and Cheng's staging system). Results: The postoperative exercise level of the two groups recovered to more than 90% of the normal level (91.2% ± 11.2% in group A and 90.9% ± 13.3% in group B, n.s.). The average time of group A and group B to return to preinjury sports activity was respectively 4.4 ± 1.0 months and 4.4 ± 1.2 months with no significant difference (p = 0.716). No significant differences were found in the preoperation VAS pain score, AOFAS score, and Tegner score between the two groups. The postoperative VAS pain score in group A was significantly higher than that in group B (0.8 ± 1.7 vs. 0.3 ± 0.8, p = 0.027), but the difference was not clinically important. The postoperative VAS pain score of patients with stage D-F lesions was significantly higher than that of patients with stage B-C lesions (1.3 ± 2.1 vs. 0.3 ± 0.9, p = 0.038). Conclusions: For the severe acute ankle sprain combined with OCL, the simultaneous arthroscopic treatment and open lateral ankle ligament repair achieved good mid- to long-term outcomes. Except that the pain was more pronounced than in the control group, there were no differences in other outcomes. Postoperative pain was positively correlated with the grade of OCL.

The effectiveness and sustainability of supervised balance training in chronic ankle instability with grade III ligament injury: a one-year prospective study.

BACKGROUND: To determine the effectiveness and sustainability of supervised balance training in people with chronic ankle instability (CAI) with grade III ligament injury. METHODS: Twenty young adults (12 males and 8 females) diagnosed with CAI with grade III ligament injury underwent 3 months of supervised balance training. The self-reported functional questionnaire, plantar pressure (walking and single leg standing), and isokinetic ankle strength were consecutively evaluated at pre-training, 3 months, 6 months and one year. Paired T tests were used to explore changes in muscle strength and plantar pressures following the supervised balance training. According to whether the patient had sprain recurrence, the patients were divided into sprain recurrence group and control group. The risk factors of sprain recurrence were explored with univariate analysis and multivariable logistic regression. RESULTS: The self-reported functional scores, the plantar pressure distribution and the muscle strength showed significant immediate improvements after 3 months of supervised balance training. At 6 months post-training, peak force under 2nd metatarsal, time to peak force under the medial hindfoot, time to boundary measurements and dorsiflexion, and eversion strength were partly declined to the pre-training level. 16 patients (80%) resumed the daily life and sports without sprain recurrence during the follow-up. Four patients (20%) reported ankle sprain during the follow-up, and the sprain recurrence group showed significantly higher Beighton scores (p = 0.012) and weaker initial inversion strength (p = 0.022) than the control group. CONCLUSIONS: Three months' of supervised balance training could effectively improve postural control and muscle strength of CAI cases with grade III ligament injury, although these improvements would partially deceased over time. Additional strength exercises for dorsiflexion and eversion should be supplemented from 6 months. Higher Beighton score and initial inversion muscle strength weakness might increase the risk of sprain recurrence. TRIAL REGISTRATION: ChiCTR, ChiCTR1900023999, Registered 21 June 2019, https://www.chictr.org.cn/edit.aspx?pid=39984&htm=4.

Open versus endoscopic excision of a symptomatic os trigonum: a comparative study of 41 cases.

PURPOSE: To compare the clinical results of a consecutive series of 43 cases of excision of a symptomatic os trigonum performed with an open versus hindfoot endoscopic technique. METHODS: From 1994 to 2007, 43 patients underwent a symptomatic os trigonum excision. A subjective satisfaction questionnaire and a visual analog scale score for pain were obtained, and the American Orthopaedic Foot & Ankle Society ankle and hindfoot score and the time to return to previous sports level were determined in 41 of 43 patients at follow up. Of the ankles, 16 had an open os trigonum excision and 25 had hindfoot endoscopic surgery. Group A (16 ankles, open surgery) and group B (25 ankles, endoscopic excision) were comparable concerning age, sex, profession, and concomitant injury of the ankle. RESULTS: At follow-up evaluation (12 to 86 months after surgery), group B had a significantly shorter mean time to return to previous sports level. There was no difference in postoperative visual analog scale score, American Orthopaedic Foot & Ankle Society score, subjective satisfaction rating, or rating of sensory nerve loss between the 2 groups. CONCLUSIONS: Both open surgery and hindfoot endoscopic excision of a symptomatic os trigonum were effective and safe. Patients with an endoscopic excision had a shorter time to return to previous sports level. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Repair of Achilles sleeve avulsion: a new transosseous suture technique.

BACKGROUND: Achilles sleeve avulsion usually occurs from pre-existing insertional Achilles tendinopathy, leaving a calcific spur at the insertional site. The purpose of this study was to introduce a new technique using the spur base on the insertional site to drill the suture tunnel to repair Achilles sleeve avulsion. METHODS: In total, 11 patients diagnosed with Achilles sleeve avulsion underwent this new surgical technique and were followed for a mean time of 40 months. Clinical outcomes were measured using the visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, Victorian Institute of Sports Assessment-Achilles (VISA-A) score, Tegner score, and time taken to return to activities. Preoperative and postoperative MRI, the ability to perform heel rise, and complications were also evaluated. RESULTS: All cases (11/11) had insertional Achilles tendinopathy with calcific spur formation on the tendon's insertion. At final follow-up, the average VAS score improved from 5.3 to 0.1, AOFAS score improved from 44.8 to 97.9, VISA-A score improved from 23.6 to 96.6, and Tegner score improved from 0.9 to 4.9. Tendinopathy symptoms were eliminated. Patients returned to daily activities, work, and sports 3.5 months, 2.8 months, and 12.3months after operation, respectively. Patients took an average of 18.1 weeks after operation to perform the single heel rise test. No severe complications such as infection and rerupture were observed. CONCLUSION: Our new transosseous suture technique is a promising alternative option in treating Achilles sleeve avulsion. More cases and longer follow up are needed in order to find the best reconstructive option for this pathology. LEVELS OF EVIDENCE: Level IV.

Risk Factors for Osteochondral Lesions and Osteophytes in Chronic Lateral Ankle Instability: A Case Series of 1169 Patients.

BACKGROUND: Osteochondral lesions (OCLs) and bony impingement are common secondary lesions of chronic lateral ankle instability (CLAI), but the risk factors that predict OCLs and bony impingement are unknown. PURPOSE: To analyze the risk factors for the development of OCLs and osteophytes in patients with CLAI. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Patients diagnosed with CLAI at our institution from June 2007 to May 2018 were enrolled. The assessed potential risk factors were age, sex, postinjury duration, body mass index, injury side, and ligament injury type (isolated anterior talofibular ligament [ATFL] injury, isolated calcaneofibular ligament [CFL] injury, or concomitant ATFL and CFL injuries). Univariate and multivariate logistic regression analyses were performed to evaluate the association between these factors and the presence of OCLs and osteophytes. RESULTS: A total of 1169 patients with CLAI were included; 436 patients (37%) had OCLs and 334 (31%) had osteophytes. The presence of OCLs was significantly associated with the presence of osteophytes (P < .001). Male sex and older age were significantly associated with the presence of OCLs in the medial and lateral talus. A postinjury duration of 5 years or longer was significantly associated with the presence of OCLs in the medial talus (odds ratio [OR], 1.532; 95% CI, 1.023-2.293; P = .038) but not in the lateral talus. ATFL and CFL injuries were both significantly associated with the presence of lateral OCLs. Risk factors for the presence of osteophytes were male sex, older age, postinjury duration 5 years or longer, and CFL injury. Patients with concomitant ATFL and CFL injuries were significantly more likely to have osteophytes than were patients with single-ligament injuries (P = .018). CONCLUSION: Risk factors for OCLs and osteophytes were postinjury duration of 5 years or longer, older age, and male sex. ATFL injury was associated with the presence of lateral OCLs, whereas CFL injury was associated with the presence of lateral OCLs and osteophytes. Patients with these risk factors should be closely monitored and treated to reduce the incidence of ankle arthritis.